The following Preferred Drug List is an abbreviated version of commonly prescribed medications. This list is intended to be a guide and prescribers should still use generics when possible. Drugs listed in CAPS and Italics are Brand Drugs and generic products are listed in lowercase letters.
A ARISTADA [INJ] bupropion ext-release COLCRYS
acetaminophen/codeine ARNUITY ELLIPTA buspirone COMBIGAN
ACTEMRA [INJ] ASMANEX HFA butalbital/ acetaminophen/ COMBIPATCH caffeine acyclovir ASMANEX TWISTHALER COMBIVENT RESPIMAT BYSTOLIC ADEMPAS atenolol COMETRIQ C ADVAIR DISKUS atenolol/chlorthalidone COPAXONE [INJ] CABOMETYX ADVAIR HFA atorvastatin CORLANOR CARAC AFSTYLA [INJ] AUBAGIO COSENTYX [INJ] carbidopa/levodopa AIMOVIG [INJ] AUSTEDO CREON carvedilol/ER AJOVY [INJ] AVONEX [INJ] cyanocobalamin [INJ] cefdinir AKYNZEO AZASITE cyclobenzaprine cefuroxime axetil albuterol nebulization azelastine nasal spray D solution celecoxib azithromycin DALIRESP alendronate cephalexin AZOPT DAYTRANA allopurinol CERDELGA B DESCOVY
ALPHAGAN P 0.1% CEREZYME [INJ] MEDONE ACCESS PREFFEREDDRUG LIST
BD AUTOSHIELD DUO desloratadine alprazolam NEEDLES CETROTIDE [INJ]
20 desonide
ALREX BD ULTRAFINE INSULIN chlorhexidine gluconate
20 desvenlafaxine succinate ER SYRINGES amiodarone chlorthalidone BD ULTRAFINE PEN dexamethasone amitriptyline NEEDLES CIMDUO DEXCOM G4/G5/G6 amlodipine BELBUCA CIPRODEX DEXILANT amlodipine/benazepril BELSOMRA ciprofloxacin dexmethylphenidate ext- amlodipine/valsartan BELVIQ, BELVIQ XR citalopram release
amoxicillin benazepril clarithromycin dextroamphetamine/ amphetamine amoxicillin/potassium benzonatate CLENPIQ clavulanate dextroamphetamine/ BEPREVE clindamycin hcl amphetamine ext-release AMPYRA BETASERON [INJ] clindamycin phosphate diazepam anastrozole BETHKIS clindamycin diclofenac sodium delayed- ANDRODERM phosphate/benzoyl peroxide release bisoprolol/hctz ANDROGEL 1.62% clobetasol propionate dicyclomine BOSULIF ANORO ELLIPTA clomiphene citrate digoxin BREO ELLIPTA apri clonazepam diltiazem ext-release BRILINTA APRISO clonidine diphenoxylate/atropine budesonide nebulization ARANESP [INJ] suspension clopidogrel divalproex delayed-release
aripiprazole bupropion clotrimazole/ divalproex ext-release betamethasone dipropionate
EFFECTIVE 1/1/2020 1
DIVIGEL estradiol patch G hydroxychloroquine
donepezil ESTRING gabapentin hydroxyzine hcl
DOVATO eszopiclone gemfibrozil hydroxyzine pamoate
doxazosin EUFLEXXA [INJ] GENVOYA HYSINGLA ER
doxycycline hyclate EVEKEO gildess fe I
doxycycline monohydrate ezetimibe GILENYA ibandronate
DUAVEE F GILOTRIF IBRANCE
DULERA famotidine glimepiride ibuprofen
duloxetine delayed-release FARXIGA glipizide ILEVRO
DYMISTA fenofibrate glipizide ext-release INBRIJA
E fenofibrate micronized GLASSIA [INJ] INCRUSE ELLIPTA
EDARBI fenofibric acid delayed- GLUCAGEN [INJ] indomethacin release EDARBYCLOR GLUCAGON [INJ] INLYTA fentanyl patch ELIDEL glyburide INVELTYS FETZIMA
ELIGARD GLYXAMBI INVOKAMET MEDONE ACCESS PREFFEREDDRUG LIST
FIASP ELIQUIS GONAL-F, GONAL-F RFF, INVOKAMET XR
20 FINACEA GONAL-F RFF REDI-JECT
ELOCTATE [INJ] [INJ] INVOKANA
finasteride
20
EMGALITY [INJ] GRANIX [INJ] irbesartan FLOVENT DISKUS enalapril GRASTEK IRESSA FLOVENT HFA ENBREL [INJ] guanfacine ext-release isosorbide mononitrate ext- fluconazole release ENDOMETRIN H fluocinonide J enoxaparin [INJ] HARVONI fluoxetine 60 mg tab JANUMET, JANUMET XR ENSTILAR HUMALOG [INJ] fluticasone nasal spray JANUVIA ENTRESTO HUMATROPE [INJ] FOCALIN XR 25 MG, 35 MG JARDIANCE EPCLUSA HUMIRA [INJ] folic acid JENTADUETO, JENTADUETO EPIDUO FORTE HUMULIN [INJ] XR FORTEO [INJ] EPIPEN, EPIPEN JR [INJ] hydralazine JUBLIA FRAGMIN [INJ] ergocalciferol hydrochlorothiazide JULUCA FREESTYLE KITS/METERS;
ERLEADA FREESTYLE FREEDOM, hydrocodone/ junel fe
FREESTYLE FREEDOM LITE, acetaminophen erythromycin eye ointment FREESTYLE INSULINX K FREESTYLE LITE FREESTYLE hydrocodone/ ESBRIET ketoconazole topical TEST STRIPS; FREESTYLE, chlorpheniramine polistirex ext-release escitalopram FREESTYLE INSULINX, KISQALI FREESTYLE LITE, hydrocodone/homatropine esomeprazole magnesium KITABIS PAK delayed-release furosemide hydrocortisone topical KOVALTRY [INJ] estradiol FYCOMPA hydromorphone
EFFECTIVE 1/1/2020 2
2019MEDONE ACCESS PREFFEREDDRUG LIST
L mesalamine N olmesartan/hctz
labetalol metaxalone nabumetone olmesartan/amlodipine/hct
lamotrigine metformin NAMZARIC olopatadine REDDRUG LIST lansoprazole delayed-release metformin ext-release naproxen, naproxen sodium omeprazole delayed-release
LANTUS [INJ] methimazole NARCAN ODACTRA
latanoprost eye solution methocarbamol NASCOBAL ondansetron
LATUDA methotrexate neomycin/polymyxin/ ondansetron orally hydrocortisone ear drops disintegrating tablets LETAIRIS methylphenidate NEUPOGEN [INJ] ONETOUCH KITS/METERS; LEVEMIR [INJ] methylphenidate ext-release ULTRAMINI, VERIO, VERIO NEUPRO FLEX, VERIO IQ, VERIO SYNC levetiracetam methylprednisolone NEXIUM PACKETS ONETOUCH TEST STRIPS; levocetirizine metoclopramide hcl ULTRA, VERIO niacin ext-release levofloxacin metoprolol succinate ext- ONEXTON release nifedipine ext-release levothyroxine sodium OPSUMIT metoprolol tartrate nitrofurantoin monohydrate/ lidocaine patches macrocrystal ORACEA metronidazole LINZESS MEDONE ACCESS PREFFE NITYR ORENITRAM ER metronidazole topical liothyronine NIVESTYM [INJ] ORLISSA 20 metronidazole vaginal gel
LIPOFEN
NORDITROPIN [INJ] ORTHOVISC [INJ] 20
microgestin fe lisinopril lisinopril/hctz nortriptyline OTEZLA minocycline LIVALO NOVOEIGHT [INJ] OTREXUP [INJ] MIRENA LOKELMA NOVOFINE AUTOSHIELD OVIDREL [INJ] mirtazapine NEEDLES LO LOESTRIN FE oxcarbazepine MIRVASO NOVOFINE NEEDLES lorazepam oxybutynin ext-release moderiba NOVOLIN [INJ] losartan oxycodone mometasone NOVOLOG [INJ] losartan/hctz oxycodone/ acetaminophen mononessa NOVOTWIST NEEDLES LOTEMAX OXTELLAR XR MONOVISC [INJ] NUCYNTA, NUCYNTA ER lovastatin OXYCONTIN montelukast NUEDEXTA LUCEMYRA OZEMPIC [INJ] morphine sulfate ext-release NUVARING LUPRON DEPOT [INJ] P MOVANTIK nystatin oral suspension LUPRON DEPOT-PED [INJ] pantoprazole delayed- MULTAQ nystatin topical LUZU release multivitamins/fluoride O M paroxetine mupirocin ODEFSEY MAVYRET PAZEO MUSE OFEV meclizine penicillin v potassium MYRBETRIQ olanzapine medroxyprogesterone PENTASA olmesartan meloxicam PERFOROMIST
EFFECTIVE 1/1/2020 3
PHOSLYRA QBREXZA sertraline tamoxifen
PICATO QNASL sildenafil tamsulosin ext-release
pioglitazone QSYMIA SILENOR TASIGNA
PLEGRIDY [INJ] QUDEXY SIMPONI 100 MG [INJ] TAZORAC (gel and 0.05% cream) polymyxin/trimethoprim eye quetiapine simvastatin solution TECFIDERA QUILLICHEW ER SKYRIZI [INJ] PRALUENT [INJ] TEKTURNA QUILLIVANT XR SOLIQUA [INJ] pramipexole TEKTURNA HCT QVAR SOMATULINE DEPOT [INJ] pravastatin temazepam R SOOLANTRA pred mild terazosin rabeprazole delayed-release SOVALDI prednisolone acetate eye terconazole vaginal suspension RAGWITEK SPIRIVA HANDIHALER testosterone cypionate [INJ] prednisolone sodium raloxifene SPIRIVA RESPIMAT phosphate timolol maleate eye solution ramipril spironolactone prednisone tizanidine ranitidine sprintec PREMARIN CREAM TOBI PODHALER
RASUVO [INJ] SPRYCEL MEDONE ACCESS PREFFEREDDRUG LIST PREMARIN TABS TOBRADEX OINTMENT REBIF [INJ] STELARA [INJ]
20 PREMPHASE TOBRADEX ST
RECTIV STIOLTO RESPIMAT
tobramycin eye solution 20
PREMPRO RELISTOR [INJ] STRIVERDI RESPIMAT PREPOPIK tobramycin/ dexamethasone RELISTOR TABLETS SUBOXONE SL FILM eye suspension PROAIR HFA REMICADE [INJ] sulfamethoxazole/ topiramate PROAIR RESPICLICK trimethoprim RENVELA Tablets TOUJEO SOLOSTAR [INJ] PROCRIT [INJ] sumatriptan REPATHA [INJ] TOVIAZ PROCTOFOAM-HC SUNOSI RESTASIS TRACLEER progesterone micronized SUPREP RINVOQ ER TRADJENTA PROLASTIN C [INJ] SYMBICORT risperidone tramadol PROLENSA SYMLINPEN [INJ] rizatriptan TRAVATAN Z promethazine SYMPROIC ropinirole trazodone promethazine/ SYMFI rosuvastatin dextromethorphan TREMFYA [[INJ] SYMFI LO RUCONEST [INJ] propranolol TRESIBA [INJ] SYMJEPI [INJ] RYTARY propranolol ext-release TREXIMET SYNJARDY, SYNJARDY XR S PULMICORT FLEXHALER triamcinolone topical T SAPHRIS PYLERA triamterene/hctz TACLONEX SUSPENSION SAVELLA trinessa TALTZ SAXENDA Q TRINTELLIX TALZENNA SEREVENT DISKUS
EFFECTIVE 1/1/2020 4
2019MEDONE ACCESS PREFFEREDDRUG LIST
tri-sprintec valsartan/hctz VICTOZA [INJ] YUPELRI
TROKENDI XR VASCEPA VIBERZI Z
TRULANCE VELPHORO W ZARXIO [INJ]
TRULICITY [INJ] venlafaxine warfarin ZELAPAR
TRUSOPT venlafaxine ext-release X ZENPEP
TYMLOS [INJ] VENTOLIN HFA XARELTO ZOHYDRO ER
TYSABRI [INJ] verapamil ext-release XELJANZ, XELJANZ XR zolpidem
U VESICARE XIFAXAN zolpidem ext-release
UCERIS RECTAL FOAM VIIBRYD XIGDUO XR ZOMIG NASAL
UDENYCA [INJ] VIMPAT XIIDRA ZOVIRAX CREAM
UPTRAVI VIOKACE XTANDI ZUBSOLV
V VIZIMPRO XULTOPHY [INJ] ZYLET
valacyclovir VOSEVI Y ZYTIGA (500MG
valsartan VYVANSE YONSA
MEDONE ACCESS PREFFEREDDRUG LIST
Examples of Non-Preferred Medications with Selected Perferred Alternatives The following is a list of non-preferred brand-name medications with examples of select alternatives that are preferred. Column 1 lists
20 examples of non-preferred medications. Column 2 lists some preferred alternatives that can be prescribed which may result in a lower
copay . This list is not all inclusive and subject to change.
20
Non-Preferred Medications Preferred Formulary Alternative(s)
ABSORICA amnesteem, claravis, myorisan, zenatane ACCU-CHEK METERS STRIPS FREESTYLE METERS/STRIPS, ONETOUCH METERS/STRIPS ADAGEN REVCOVI AKYNZEO (capsule) granisetron, ondansetron, aprepitant, VARUBI TABLETS ALVESCO ARNUITY ELLIPTA, ASMANEX HFA/TWISTHALER, FLOVENT DISKUS/HFA, PULMICORT FLEXHALER, QVAR AMITIZA LINZESS, TRULANCE APIDRA HUMALOG, NOVOLOG, FIASP ARCAPTA NEOHALER SEREVENT DISKUS, STRIVERDI RESPIMAT ARZERRA IMBRUVICA, VENCLEXTA ATROVENT HFA ipratropium bromide (inhalation solution), INCRUSE ELLIPTA, SPIRIVA RESPIMAT BECONASE AQ budesonide, flunisolide, fluticasone, mometasone, QNASL BEVESPI AEROSPHERE ANORO ELLIPTA, STIOLTO RESPIMAT BRAVELLE GONAL-F, GONAL-F RFF, GONAL-F RFF REDI-JECT BREEZE, CONTOUR METERS/STRIPS FREESTYLE METERS/STRIPS, ONETOUCH METERS/STRIPS BUTRANS buprenorphine (patch), BELBUCA BYETTA, BYDUREON, BYDUREON TRULICITY, VICTOZA, OZEMPIC BYVALSON valsartan, BYSTOLIC, atenolol, bisoprolol, carvedilol ER, metoprolol succinate, propranolol ER
EFFECTIVE 1/1/2020 5
CIMZIA ACTEMRA, COSENTYX, ENBREL, HUMIRA, OTEZLA, REMICADE, STELARA, XELJANZ, XELJANZ XR COMPLERA ODEFSEY CONTRAVE BELVIQ, BELVIQ XR, QSYMIA, SAXENDA CRINONE ENDOMETRIN DAKLINZA EPCLUSA, HARVONI, MAVYRET, SOVALDI, VOSEVI DIABETIC SYRINGES & PEN NEEDLES ITEMS MANUFACTURED BY BD & NOVO (i.e. NOVOFINE NEEDLES, BD ULTRAFINE INSULIN SYRINGES) EPOGEN ARANESP, PROCRIT FIRDAPSE RUZURGI FOLLISTIM AQ GONAL-F, GONAL-F RFF, GONAL-F RFF REDI-JECT FORTESTA ANDROGEL 1.62%, FULPHILA NEULASTA, UDENYCA GELNIQUE MYRBETRIQ, TOVIAZ, VESICARE GEL-ONE EUFLEXXA, MONOVISC, ORTHOVISC GENOTROPIN HUMATROPE, NORDITROPIN GENVISC 850 EUFLEXXA, MONOVISC, ORTHOVISC GRALISE gabapentin, pregabalin HEXALEN No Alternatives Recommended
MEDONE ACCESS PREFFEREDDRUG LIST INFLECTRA REMICADE
JADENU deferasirox
20 KADIAN hydromorphone ext-release, morphine sulfate ext-release,
oxymorphone ext-release, HYSINGLA ER, NUCYNTA ER,
20
OXYCONTIN KAZANO JANUMET, JANUMET XR, JENTADUETO, JENTADUETO XR KOMBIGLYZE XR JANUMET, JANUMET XR, JENTADUETO, JENTADUETO XR LARTRUVO No Alternatives Recommended LEVITRA CIALIS, sildenafil LOESTRIN FE junel fe MIRCERA ARANESP, PROCRIT MITIGARE allopurinol, COLCRYS, ULORIC MOXEZA ciprofloxacin (eye drops), gatifloxacin, levofloxacin (drops), moxifloxacin (drops), ofloxacin (eye drops) MULPLETA DOPTELET NATESTO ANDROGEL 1.62%, NESINA JANUVIA, TRADJENTA NEVANAC bromfenac, diclofenac sodium, ketorolac, ILEVRO, PROLENSA NUTROPIN AQ HUMATROPE, NORDITROPIN NUWIQ ADVATE, AFSTYLA, KOGENATE FS, KOVALTRY, NOVOEIGHT OLYSIO EPCLUSA, HARVONI, MAVYRET, SOVALDI, VOSEVI OMNARIS budesonide, flunisolide, fluticasone, mometasone, QNASL OMNITROPE HUMATROPE, NORDITROPIN ONGLYZA JANUVIA, TRADJENTA ORFADIN NITYR PANCREAZE CREON, ZENPEP PERTZYE CREON, ZENPEP
EFFECTIVE 1/1/2020 6